Cannot miss / life threats
Cannot miss / life threats
Diagnostic flow β check first
Diagnostic flow β check first
- Age >50 or vasculopath β bedside aortic US FIRST (rule out AAA).
- Reproductive-age female β Ξ²-hCG before imaging (ectopic).
- Fever + CVA tenderness β UA + blood cultures β think pyelo / infected stone.
- Hematuria + colicky writhing pain β non-contrast CT (stone protocol).
- Pain out of proportion + AF / vasculopath β consider renal infarct (CTA, LDH).
- Right-sided pain + cough/dyspnea β CXR for lower lobe pneumonia.
Differential diagnosis β checklist
0/22
Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.
Urologic0/6
Vascular0/2
GI / hepatobiliary0/4
Gyn0/3
MSK / neuro0/4
Pulmonary0/3
Initial ED workup
Bedside0/4
- Vitals + bedside aortic US (esp >50 y)
- Pregnancy test
- UA / urine dip
- ECG if older
Labs0/5
- UA + culture
- CBC, BMP, lactate
- Lipase, LFTs
- Coags / type & screen if AAA suspected
- Ξ²-hCG
Imaging0/4
- Bedside US (aorta, hydronephrosis, gallbladder)
- Non-contrast CT abd/pelvis (stone protocol)
- CTA if vascular concern
- Pelvic US for gyn cause
Initial management0/5
- IV fluids
- Analgesia (ketorolac if no contraindication; opioid if needed)
- Antiemetic
- Antibiotics if infected stone / pyelo
- Urology consult for obstructed infected system
ED next steps
ED next steps
- Vitals + bedside aortic US in any patient >50 before anchoring on stone.
- Ξ²-hCG, UA, BMP, lactate, type & screen if vascular concern.
- Non-contrast CT abd/pelvis (stone protocol); add contrast if AAA / abscess suspected.
- Analgesia: ketorolac 15β30 mg IV (if no AKI/bleeding) Β± opioid; antiemetic.
- IV fluids; antibiotics (ceftriaxone) if pyelo or infected stone.
- Urgent urology consult for obstructed + infected system β stent or nephrostomy.
- Disposition: admit if septic, AKI, intractable pain, or stone >6 mm; OB/vascular consults as indicated.
Pearls / pitfalls
Pearls
- First-time 'renal colic' in a patient >50 β rule out AAA before anchoring.
- Fever + flank pain + obstructing stone = urologic emergency (decompression).
- Right lower lobe pneumonia can mimic flank/abdominal pain β get a CXR.